Cutting Out Stigma: Findings From a Pilot Implementation Trial of a Barbershop-Based HIV Stigma Reduction and Health Promotion Intervention in the Southern United States.

INTRODUCTION: Black Americans and individuals in the Southern United States bear a disproportionate burden of HIV. To address stigma, a key contributor to these inequities, we developed Cutting Out Stigma (COS), a barbershop-based education and multimedia intervention.

METHODS: We recruited and trained Tennessee (U.S.) barbers as COS Men's Health Ambassadors and invited them to participate in a 6-month COS pilot implementation trial from September 2024 to March 2025. COS barbers provided sexual health education, referrals to HIV (and other ancillary) services for barbershop clients and shared relevant study and barber-created social media posts. Using the RE-AIM framework, we assessed reach (social media and barbershop-based), preliminary effectiveness (barber-level HIV knowledge improvement, role effectiveness and resource connection), intervention adoption and implementation (feasibility, acceptability, appropriateness at baseline and endline). Data sources included validated pre- and post-implementation surveys, social media analytics, weekly self-report forms and in-depth interviews (IDIs). Quantitative data were summarized descriptively, with mixed-effects models estimating change over time; IDI analyses helped interpret effectiveness outcomes.

RESULTS: Sixty-seven barbers completed COS training. Among 57 successfully contacted post-training, 50 barbers (87.7%) enrolled in the pilot trial across 26 barbershops. The pilot reached an estimated 4464 barbershop client encounters, with 62.0% of barbers engaging ≥6 clients weekly. Estimated social media reach averaged 57,462 users monthly. Implementation outcomes remained high: baseline/endline scores were 4.8/4.8 for feasibility, 4.9/4.9 for acceptability and 4.8/4.9 for appropriateness (each out of 5). HIV knowledge improved following training, and barbers reported high effectiveness as health ambassadors (median effectiveness 8 of 10; IQR: 7-9). Barbers facilitated an estimated 3096 referrals, primarily for HIV testing (71.0%) and pre-exposure prophylaxis (PrEP) (70.0%). IDIs helped explain these patterns: barbers described moving from transmission myths towards actionable understanding of HIV prevention, reported shifts in personal attitudes as they grew in their new role, and perceived normalizing HIV discussion and making resource referrals as "shop talk" that could reduce community stigma. Barbers also described client-level early prevention behaviours (e.g. condom uptake, PrEP inquiries), though they felt fear of judgement created intention-behaviour gaps for a few clients.

CONCLUSIONS: COS demonstrated high feasibility, acceptability and suggested preliminary effectiveness in reducing HIV stigma and promoting prevention through trusted barbershop settings. Integrating community-based and digital strategies offers a promising model to tackle HIV stigma and advance Ending the HIV Epidemic goals.